The diseases of children

Front matter

Glass /) ^UzS

Book / S

Copyright N^— i ^ / p

Preface To First Edition

This book has been written not for the specialist, but with the needs of the general practitioner and student in view, and the diseases of children have been described as they are seen by the busy practitioner in his daily rounds.

Believing that the question of infant feeding is one of the most important which confronts us, much more space has been devoted to that subject than is given other important ones. We wish to interest the general practitioner in milk, its care and handling, the necessity for the formation of certified milk commissions, and the establishment of milk depots where certified milk may be placed within the reach of the poor.

Each disease is considered in a methodical manner. Special attention is given the dietetic and hygienic management, and the medicinal treatment is considered quite fully, with the reproduction of many tried formulae.

Chapters have been included on Diseases of the Eye, Ear, Nose and Throat, and the Skin.

Temperature charts have been reproduced in a number of places, with the hope that this valuable clinical aid will be more often employed in private practice than it is at present. A world of valuable data and statistics is lost because of the practitioner's failure properly to record bedside notes in daily visits to the private patient. We would encourage this feature of the work.

Thanks are herewith extended to Dr. Wm. Britt Burns, of Memphis, for the preparation of the chapter on Malaria; to Dr. Louis Frank and Dr. I. Lederman for valuable suggestions ; to Mrs. Mary West Fullenlove for painstaking preparation of the manuscript, and to the publishers for their many courtesies during the publication of the book.

Henry Enos Tuley.

Preface To Second Edition

The retirement of the Southern IMeclieal Publishing Company from the field of book publishing, and the acquirement of the publication rights to this book by the C. V. Mosby Company, necessitated the entire resetting of the book when it became apparent a second edition was needed. This has enabled the author to rewrite many chapters and make additions throughout the text that became necessary because of advancements and discoveries in pediatrics since 1909. Advantage has been taken also of this opportunity to make many corrections in the make-up of the book, as many typographical errors crept into the first edition.

The general character of the book has been kept the same. The needs of the general practitioner and student have been kept in the front alwaj^s and as far as possible the views of the authorities in diseases of children have been given as well as the experience and observation of the author.

New food formulae have been added and the suggestive standards and methods for the production of Certified milk as adopted by the American Association of Medical ]\Iilk Commissions have been reproduced in full in the appendix, believing they may prove of value to many who may contemplate organizing a medical milk commission, or help to make better commissioners of those already members of one.

The old classification of the diseases of the gastro-intestinal tract has been retained with the full knowledge of its being unsatisfactory, but in tlie absence of a better one it was thought best to adhere to the old.

A number of new illustrations have been added to this edition, some to take the place of ones which had been lost, others entirely new. We are indebted to several authors and medical journals for the use of special cuts.

Advantage is taken of this opportunity to express my thanks

PREFACE TO SECOND EDITION.

to the Publishers for their many courtesies, to my secretary, Miss Alice Lee Ford, for her invaluable assistance in the preparation of the manuscript, and for the generous reception accorded the first edition, which we bespeak for the second edition as well.

Henry Enos Tuley.

Aug. 1st, 1913.

Chapter I. Page

Anatomy of Ixfaxts 17-24

Circulation — Head — Ear — Xose — Spine — Thorax — Larynx — Trachea — Lungs — -Thymus Gland — Bronchial Glands — Fetal Heart — Stomach — Sigmoid Flexure — Liver — Spleen — Kidneys — Testicles — L'terus — Ovaries — Heterotoxia.

CHAPTER II. The New-boen 25-35

Asphyxia — Care of the New-born^ — Preparation for the Baby — Care of the Napkins — ^^The Nursery.

CHAPTER III. Diseases and Injuries of the Xew-born 36-52

Caput Succedaneum — Cephalhematoma — Umbilical Hemorrhage — Granulating Umbilicus — Hemorrhage — L^mbilical Hernia — Atelectasis — Icterus — Sepsis — Injuries — Mastitis — Starvation Temperature — Cerebral Hemorrhage — Tetanus — Sclerema.

Dosage — Methods of Calculation — Varieties of Medication — 'The Bath — Pack — Local Application — Stomach Washing — Colon Irrigation — Urine — Inunction.

Chapter VII

Infant Feeding — Breast Feeding — Nursing Motlier — Breast Milk — Wet Nurse — Weaning — Combined Feeding — Artiticial Feeding —

CONTENTS.

PAGE

Cow's Milk — Certified Milk — Foreign Matter in Milk — Changes in Milk from Bacteria — Market Milk — Tuberculosis and Milk — Epidemics due to Milk — Care of Milk in Home — Morbidity and Mortality Statistics Influenced by Milk — Sterilization and Pasteurization — Composition of Milk — Inspection of Dairies — Care of Bottle and Nipples — Modified Milk — Top Milk— Condensed Milk — Whey — Calories — Artificial Foods — Diet after First Year — Gavage — Eectal Feeding,

CHAPTER VIII. Diseases of the Nose, Throat and Pharynx 152-171

Acute Rhinitis^ — Chronic Rhinitis — Atrophic Rhinitis — Epistaxis — Nasal Polypi; — Diseases of the Tonsils — Acute Catarrhal Tonsillitis — Follicular Tonsillitis — Chronically Enlarged Tonsils — Uvulitis — Peritonsillar Abscess — Retropharyngeal Abscess — Adenoids — Diseases of Larynx — Acute Catarrhal Laryngitis — Congenital Laryngeal Stridor.

Chapter IX

Diseases of the External Auditory Canal — Furunculosis — Impacted Wax — The Middle Ear — Acute Tubo-tympanic Catarrh — Acute Catarrhal Otitis Media — Acute Suppurative Otitis Media — Mastoiditis.

Chapter X

Eye Strain — Blepharitis — Herdeolum — Conjunctivitis — Trachoma — Grandular Conjunctivitis — Vernal Catarrh of the Conjunctiva — Diphtheritic Conjunctivitis — Phlyctenular Conjunctivitis — Ophthalmia Neonatorum — Diseases of the Cornea — Pterygium — Phylctenular Keratitis — Intestitial Keratitis.

CHAPTER XL

Diseases of the Respiratory Tract 200-232

Foreign Bodies in Bronchial Tubes — Asthma — Atelectasis — Acute Catarrhal Bronchitis — Chronic Catarrhal Bronchitis — Emphysema — Broncho-pneumonia — Lobar Pneumonia — Pleurisy — Empyema — Gangrene of Lung.

CHAPTER XII. Diseases of the Digestive System 233-28B

Diseases of the Lips — Ulcerations at Angle of Mouth — Herpes — Diseases of the Tongue — Diseases of the Mouth — Bednar's Aphthse

CONTENTS,

PACK — Stomatitis— Thrush — Raniila — Tongue-tie — Riga's Disease — Alveolar Abscess— Fistula of Neck — Acute Esophagitis — Stenosis of Pylorus — Diseases of Stomach and Intestines — The Feces — Gastric Disorders — Acute Gastric Indigestion — Acute Gastritis — Chronic Gastritis— Gastric Dilatation— Cyclic Vomiting— Colic— Gastralgia —Acute Gastro-enteric Infection — Cholera Infantum — Acute Entereolitis — Chronic Entercolitis— Constipation— Dilatation of Colon.

Chapter XVII

The Heart — Congenital Heart Disease — Pericarditis — Pericarditis with Effusion — Chronic Pericarditis — Pyopericardium — Endocarditis — Malignant Endocarditis — Chronic Endocarditis — Mitral Regurgitation — Mitral Stenosis — Aortic Regurgitation — Aortic Stenosis — Tricuspid Regurgitation — Tricuspid Stenosis — Treatment of Valvular Lesions — Functional Disorders of Heart — Bradycardia — Tachycardia — Acute Myocarditis.

Chapter XVIII

The Blood of Infancy and Childhood — Anemia — Pernicious Anemia — Chlorosis — Lymphatic Leukemia — Pseudoleukemia — Pseudoleukemia of Infants — Purpura — Hemophilia.

CONTENTS.

Chapter XIX Page

Diseases of the Lymphatic Glands 469-475

The Thymus Gland — Acute Adenitis — Chronic Adenitis — Addison's Disease — Cretinism.

Chapter XX

The Urine — Albuminuria— Pyelitis— Renal Calculus — Perinephritis — Acute Parenchymatous Nephritis — Chronic Nephritis — Chronic Interstitial Nephritis — Tumors of the Kidneys — Hydronephrosis — Enuresis — Phimosis — Paraphimosis — Hydrocele — Balanitis — Urethritis — Vulvo-vaginitis — Cystitis — Undescended Testicle.

Chapter XXII

General Considerations — Diagnostic Methods — Convulsions — Chorea — Hysteria — Epilepsy — Disorders of Sleep — Multiple Neuritis — Facial Palsy — Obstetrical Paralysis — Infantile Paralysis — Acute Myelitis — Pott's Disease — Tumors of the Spinal Cord — Syphilis of the Cord — Disseminated Sclerosis — Hereditary Ataxia — Hereditary Spastic Paralysis — Progressive Muscular Dystrophy — Meningitis — Epidemic Cerebro — Spinal Meningitis — Acute Encephalitis — Hydrocephalus — Chronic Hydrocephalus — Cerebral Palsies — Tumors of Brain and Meninges — Abscess of Brain — Intracranial Hemorrhage.

Chapter XXIII

Intertrigo — Sudamina — Pediculosis — Scabies — Ringworm — Tinea Favosa — Impetigo Contagiosa — Pemphigus — Eczema — Herpes — Pruritus — Urticaria — Psoriasis.

Appendix

Milk Modifications — Babies' Milk Fund Association Brochure — Refrigerator' — Methods and Standards for Production and Distribution of Certified Milk.

ILLUSTRATIONS

Plate I. Buccal Enantliem in Measles (Koplik's Spots) . Frontispiegie

Plate II. Life-Cycle of Plasmodium Vivax .... Facing page 3X0

Plate III. Tonsillar Diphtheria — Follicular Tonsillitis . Facing page 410

FIGURE PAGE

1. Capacity of infant's stomach . . 21

2. Size of infant's stomach, three months 22

3. Size of infant's stomach, six months 22

4. Dissection of still-born child 23

5. Funis Band Applicator 29

6. Umbilical granulation removed by ligature six weeks after birth 38 . 7. Adhesive strap for umbilical hernia 43

8. Starvation temperature chart 48

9. Hammock scale 53

10. Nurserj^ scales 54

11. Temporary and permanent teeth 58

12. Showing axillary and infra-axillary regions 62

13. Anterior regions of the chest 63

14. Posterior regions of the chest » 63

15. Position for taking rectal temperature 65

16. Examination of throat by direct illumination 67

17. Tongue depressor handle with removable wooden depressors . 68 li8. Ear specula 68

19. Bowles stethoscope with small chest piece 70

20. Position for auscultation of back 71

21. Auscultation of chest .72

22. Stanton's percussion hammer 73

23. Rubber bulb syringe 75

24. Collapsible rubber bath tub 78

25. Glass syringe 82

26. Apparatus for stomach washing 83

27. Colon irrigation 84

28. Holt's milk set 91

29. Certified Dairv No. 2 101

ILLUSTRATIONS.

FIGUEE PAGE

29ti. Certified Dairy No. 2 102

30. Certified milk bottle 104

31. Certified milk in special glasses 104

32. Curler milk pail IOC

33. Hooded milk pail 106

34. Certified milk shipping cases 100

34a. Box used for collecting samples of milk in original bottles . . 107 34b. Box used in collecting samples of milk in bulk 107

35. Sample of unsuspected but dangerous tubercular cow . . . ,110

36. Castle Pasteurizer 116

37. Hygeia Pasteurizer 116

38. Babcock butter fat test 129

39. Chapin cream dipper . . . ■ 130

40. Cross-section of human tonsil, age 11 years 156

41. Osteomyelitis following streptococcic infection from tonsillitis . 160.

42. Tonsillotome 162

43. Croup kettle 170

44. Instrument for paracentesis of the drum 176

45. Otitis media both ears, temperature chart ....... 180

46. Roller forceps for trachoma 191

47. Five-cent piece in esophagus 201

48. Vaporizer 207

49. Lobar pneumonia; crisis seventh day. (Temperature chart) . 219

50. Mucosa normal colon 283

51. Mucosa giant colon 284

52. Congenital idiopathic dilatation of the colon ..-..., 285

53. Side view, same patient as above 285

54. Eggs of oxyuris vermicularis 288

55. Eggs of ascaris lumbricoides 290

56. Head of tenia solium 293

57. Head of tenia solium , 293

58. Head of tenia saginata 293

59. Typhoid fever with reinfection, temperature. (Chart) . . .310

60. Typhoid fever; hemorrhage; perforation. (Temperature chart) 312

61. Temperature chart for 81 da^s in child with general tuberculosis 333

62. Same as above 333

63. Pellagrous dermatitis 344

ILLUSTRATIONS.

FIGUEE PAGE

04. Anopheles Crucians, Female mosquito, greatly enlarged , . . 348

05. Anopheles punctipennis, Female mosquito, greatly enlarged . 348 00. Anopheles quadrimaculatus. Female mosquito, greatly enlarged 348

07. Anopheles mosquito at rest 348

OS. Common mosquito at rest 348

69. Malarial hemoglobinuria, temperature. (Chart) 358

70. Measles, temperature. (Chart) 370

71. Measles with complicating pneumonia, temperature. (Chart) . 372

72. German measles, temperature. (Chart) 377

73. The whooping-cough belt 404

74. Eear view of the whooping-cough belt applied 404

75. Laryngeal and nasal diphtheria; intubation. (Temperature

chart) 414

76. Diphtheritic casts of trachea and bronchi 416

77. O'Dwyer Intubation Tubes 423

78. Position for intubation. First step 425

79. Intubation. Second step. Introducer about to be removed . 425

80. Position for feeding child wearing intubation tube .... 426

81. Tallquist hemoglobin scale . . 452

82. Dare's hemoglobinometer 452

S3. Locating the inter-vertebral space for lumbar puncture . . . 517

84. Lumbar puncture. Nurse holding sterile bottle to catch fluid . 517

85. X-ray of Pott's disease 546

SO. Typical attitude assumed by patient with pseudohypertrophic

muscular paralysis 554

87. Same as Fig. 86 554

88. Same as Fig. 86 554

89. Typical muscular enlargement 555

90. Pure culture of meningococcus, 30 hours old 557

91. 92, 93, 94. Series of microphotographs illustrating the change in

the cerebrospinal fluid under the influence of serum treatment with improvement 558

95. Boy of eleven, ill forty-eight hours with epidemic meningitis . 560

96. Boy of thirteen lying in the usual position of those ill with epi-

demic meningitis 560

97. Photograph of boy of ten and one-half years, taken five days after

the onset of epidemic meningitis 560

98. Hydrocephalus. Child six years old 566

ILLUSTRATIONS.

FIGURE PAGE

99. Side view same child as in Fig. 98 566

100. Pemphigus vulgaris acuta 588

101. Pemphigus, temperature. (Chart) 589

102. Westcott's milk modification chart 601

103. Haas' Materna 603

104. Deming Modifier 603

105. Hess home-made refrigerator. Horizontal section .... 631

106. Hess home-made refrigerator. Vertical section 631

Chapter I. Anatomy Of Infants

The infant's anatomy differs from that of the adult in many essential points. The chief of these is the change which takes place in the circulation immediately after birth. These may be named as follows, probably in the order of their happening : Opening of the pulmonary arteries ; closure of the foramen ovale, complete about the tenth day ; disappearance of the Eustachian valve; obliteration of the ductus arteriosus, ductus venosus and the hypogastric arteries, the latter remaining pervious from the internal iliac arteries to the bladder, known after birth as the superior vesical arteries. The umbilical vein and the ductus venosus close about the fifth day, the latter persisting in its impervious state as the round ligament of the liver. With the tying of the cord the hypogastric arteries and the vessels in the cord are obliterated.

The child's head is very soft and compressible, the bones are ununited and separated by sutures; where the sutures coalesce are the anterior and posterior fontanelles. The anterior fontanelle, at the anterior superior end of the parietal bones is larger than the posterior and quadrilateral in shape. It closes during the second year. The posterior fontanelle at the posterior inferior ends of the parietal bones is triangular in shape and smaller. It closes by the end of the first year.

As a result of moulding during birth the head in normal cases is much elongated from the chin to the occiput, and if a large caput succedaneum is present it is still further misshapen. Its normal contour is restored in a few days. The scalp is quite mobile, owing to its loose attachment to the aponeurosis. The frontal hone is divided into two equal parts ])y the frontal suture.

The sphenoidal and temporal bones consist of three separate pieces each. The mastoid cells are not present. The inferior maxilla is divided into two equal portions united by fibrous tissue at the chin.

The infant's ear differs greatly from the adult's. At birth the axis of the meatus is directed upward, the canal being smaller at the inner end. The auricle is pulled dowm'(^ard to obtain a view of the tympanum.

The Eustachian tubes in the infant are about half the length of the adult's; they are straight, and nearly horizontal, and the pharyngeal opening is about on a level with the hard palate, and smaller, relatively, than in the adult.

The uose is small in infancy and the respiratory space in the nares very limited. The nasopharynx is quite deep. It is vascular and rich in lymphoid tissue. The presence of this lymphoid tissue is a menace to infants as it becomes easily inflamed and swollen, obstructing the respiratory area.

The spine is very flexible, the bones at birth are mostly cartilaginous, the nuclei of ossification being present. Spina bifida results from a failure of the laminae to unite allowing a protrusion of the membranes of the cord or filaments of the cord itself. The upper extremities are much better developed at birth than the lower, the fetal circulation providing a venous blood to the lower extremities.

The clavicle is one of the first bones to ossify. The ossification of the long bones begins in the center of the diaphysis. The bones of the thorax are mostly cartilaginous, hence, the elasticity of this portion of the body. Several centers of ossification are present in the sternum. The larynx is higher than in the adult, being about on the level with the axis, and a view of the epiglottis and vocal cords can frequently be had without the aid of a mirror.

The trachea divides at about the third lumbar vertebra. The opening into the right lung is larger than the left, the right bronchus not having quite so wide an angle.

The lungs at birth are small and the air vesicles entirely collapsed. On removing the anterior chest wall of a still-born child the lungs do not fill the thoracic ca^dtv and the heart is

ANATOMY OF INFANTS. 19

found uncoA^ered, the thymus g:land extending usually below the base of the heart. As a result of the first deep inspiration the air vesicles are dilated, the lungs expand, fill the cavity and cover the heart. The di\asion of the right lung into three lobes is quite marked in the infant, with a deep fissure especially posteriorly between each. The lower border of the right lung posteriorly, reaches the tenth rib on the right side, and to the eleventh rib on the left side.

The thymus gland is an organ but little understood. It is present in the new-born, often being relatively of great size, gradually growing smaller after birth. It may extend as low as the fourth rib, and above the suprasternal notch. It has two lobes, and may measure 2^^ by IV2 inches. Its undue development has been supposed to be the cause of some otherwise unexplained cases of sudden death.

The hroncliial glands are located around the trachea in its lower portion and extend around the bronchi at their bifurcation. These are normally quite small, but as a result of an infection may assume quite a large size.

The fetal heart differs from that of the new-born in the presence of the interauricular opening, the foramen ovale, and the Eustachian valve, which is supposed to guide the blood from the inferior vena cava through the right auricle into the left auricle. The cavities of the right side are larger than the left, the heart weighing about two-thirds of an ounce, at birth. With the change in the circulation after birth the heart assumes more the adult type, the left side becoming larger. The apex beat is felt about the fourth interspace farther to the left than in the adult.

The fetal circulation is as follows: Leaving the placenta the blood flows through the umbilical vein to the lunbilical opening, ascending to the under surface of the liver from there through the ductus venosus, a fetal structure, to the inferior or ascending vena cava. From the inferior vena cava the stream goes into the right auricle guided by the Eustachian valve through the foramen ovale into the left auricle. From the left auricle through the mitral orifice to the left ventricle ; from the left ventricle to the ascendino: aorta, throui>h the larger vessels of the neck to the brain and upper extremities. The blood returns, via the superior or descending vena cava, to the right auricle, being largely venous in character ; from the right auricle to the right ventricle, the pulmonary arteries being impervious, the blood is carried through the ductus arteriosus, a fetal structure, to the descending aorta. Through the descending aorta the blood flows as far as the iliac vessels, a portion of it going through the external iliac to the lower extremities, the rest of the blood going through the hypogastric arteries, branches of the internal iliacs, over the summit of the bladder and under the anterior abdominal wall to the abdominal opening where these vessels become the umbilical arteries.

The umbilical opening may be patulous at birth and allow a protrusion through into the cord of a loop of the intestine, or there may be a separation of the umbilical ring after the stump of the cord falls off allowing a protrusion of intestine and the formation of an umhilical hernia. There have been a few cases reported where a coil of intestine had been included in a ligature which encircled the cord to tie the umbilical vessels.

The stomach at birth is more like the dilated end of the esophagus than a separate organ itself, due to the pyloric end being pushed downward by the left lobe of the liver, causing it to assume more of the upright position. Regurgitation of its contents is very easy because of this. The stomach at birth will hold about 1 ounce. The cardiac opening is located about opposite the first dorsal vertebra, the principal difference in the intestine is the relatively large size and length of the sigmoid flexure of the colon.

The sigmoid flexure at birth is about as long as the colon itself, the sigmoid extending frequently much beyond the median line. Owing to the shallowness of the pelvis most of the sigmoid is in the abdominal cavity.

The liver is one of the heaviest organs in the body at birth, its relative w^eight to that of the body being 1 to 18. Its growth and development are due to its receiving first the pure arterial blood as it comes from the placenta. The left lobe may extend much beyond the median line.

The spleen is small at birth, lying usually under the ninth

ANATOMY OF INFANTS.

and tenth ribs, and cannot be felt upon palpation unless enlarged. The kidneys are about on a line with each other. They are distinctly lobulated'and may be joined, forming a horseshoe kidney. On section a number of uric acid infarcts may be found.

Fi£

-Capacity of infant's stomacli (Kelley).

The suprarenal glands are relatively larger at birth than in the adult. They are highly vascular and may be the site of hemorrhage. (See report of case on page 4(/.) Tlie male urvthra will average two inches in length and shows (juite a distinct constriction at the meatus. The fossa navicularis is relativelv

THE DISEASES OP CHILDREN.

Fig. 2. — Size of infant's stomach three months (Kelley

Fig.

3 — Size of infant's stomach six months (Kelley).

ANATOMY OF INFANTS.

larger than the rest of the urethra and may be the site of the formation of a concretion or stone in late infancy.

The corona glandis is tightly covered by the prepuce, frequently adherent, with an accumulation of smegma behind the corona o-landis.

Fig. 4. — Dissection of still-l)oni child. Note tlie course of the sigmoid, relatively large size of the liver.

The testicles in the embryo are found in the abdominal cavity, below the kidneys, in the lumbar region. At about the eighth month they descend and pass out into the scrotum through the inguinal canals.

A child whose testicles are retained within the canal or cavity is called a cryptorchid, if only one has descended, a monorchid.

The uterus at birth is small, about 1 inch in length; the ovaries are found in the lumbar region in intrauterine life, and at birth are as low as the brim of the pelvis. It is estimated that upwards of 75,000 ova are in each ovary at birth.

The relative weight of the hrain at birth to the body is 1 to 8. The color is quite pale and contains a larger percentage of water than the adult brain.

HETEROTAXIA.

Irregular malpositions of viscera are occasionally observed in routine practice. These abnormalities have been exhaustively studied by Ballantyne, Osier, Arneill, Rover and Wilson.

The usual form observed is a complete transposition, of either the thoracic or abdominal organs or both.

Among the remarkable cases on record (Arneill ^ reporting 300 collected from the literature) are maintenance of fetal vascular conditions after birth; lobulated spleen or multiple spleens; one kidney; transposition of the cavities of the heart; of the lungs, liver and spleen.

The fetal condition of the heart can be made out by physical examination. The other transpositions may not be suspected until found postmortem, and unless the heart is involved the child may reach adult life; with involvement of the heart these children rarely reach puberty.

1 American Journal Medical Sciences, November, 1902.

Chapter II. The New-born

As soon as the child's head is born, and before the birth of the body, feeble attempts are made at inspiration. At this time the mouth should be wiped out promptly and freed of the mucus and fluid which it contains in order to prevent its being aspirated in the bronchial tubes, with the first deep inspiration.

Reacting to the stimulus of the air upon the skin, the first inspiration is taken and the air vesicles are dilated. The skin quickly changes from a pallid or bluish color to the normal red, and the child criea lustily. The respirations at first are shallow, often slightly irregular, and they are of the abdominal type. The chest soon becomes fully expanded and the number of respirations which at first was 60 or 70 to the minute will average about 40 at the end of the first hour.

ASPHYXIA.

"Where insufiicient air has entered the lungs of the new-born to dilate the air vesicles the child is still-horn. When some air does enter the lungs and for any reason there is an interference with the proper exchange between oxygen and carbon dioxide, the condition is called asphyxia.

Forms. — Asphyxia may be intrauterine. This form is caused by any interference with the uteroplacental circulation; as a premature or accidental separation of a portion of the placenta; knots in the cord, too tight loop or loops of the cord around the child 's neck ; long-continued labor from any cause ; compression of the cord by the after-coming head ; compression of the fetal brain by forceps operation ; death of the mother and prematurity.

Intrauterine asi)hyxia may be foretold liy tlu^ ])remature escape of meconium in vertex pres(4itations nnd by an interruption in the beat of the fetal heart, either very rapid or very slow heart sounds. In interference AAdth placental respiration.

the blood of the fetus is surcharged with carbon dioxide, an increased intestinal peristalsis and a relaxation of the sphincter occurs, allowing escape of the meconium. In breech presentation, the escape of meconium is from pressure causes entirely, and is of no significance.

If premature respiration occurs before the birth of the head, liquor amnii and mucus may be aspirated, which will mechanically act as a cause of asphyxia.

The persistence of the intrauterine apnea after birth constitutes the postnatal form of asphyxia. The chief cause of this form is an injury to the respiratory centers by prolonged labor; prematurity, the thin chest walls making it impossible for the lungs to dilate because of external atmospheric pressure, a general atelectasis following in these cases.

Symptoms. — In the intrauterine form of asphyxia, the child is born limp and the skin is pale or blue. Two forms are generally referred to, asphyxia livida and asphyxia pallida, the latter being the most profound. In the mild cases there is a very feeble intake of air, noted by slight movement of the diaphragm, strong umbilical pulsation and muscular action of the face and nose. If improvement follows, the respirations will become more regular and less spasmodic, the color will improve and the child will utter a feeble whine or cry.

Prognosis. — The prognosis in all cases of asphyxia is very grave. Atelectasis is always to be feared. If the child does not nurse well, has a persistent subnormal temperature and progressive and rapid loss in weight, the prognosis is more grave. As long as there are any heart beats to be heard one should persist in efforts at resuscitation by artificial respiration.

Treatment. — Prophylaxis of asphyxia should be borne in mind in every case of labor. Intelligent interference in cases of prolonged labor with the fetal heart as a guide is always indicated, and will prevent many cases of asphyxia. The mouth and nose should be carefully cleansed of mucus and the face not allowed to remain in the discharges upon the bed or table, if the delivery is accomplished in the dorsal position. A basin or tub which will hold enough Avater to completely cover the child's body, should be part of the equipment of every delivery room, as frequently respiration Avill be stimulated by immersing the -child in water at a temperature of 105° or 110° F., and occasionally allowing a small quantity of cold water to trickle over its chest or plunging it for a second in cold water. If this fails, resort should be had at once to the use of one of the methods of artificial respiration.

A soft catheter may be introduced into the trachea and mucus aspirated through it, if the obstruction seems to be of that nature. The suspension of the child by its feet, and tlagellalion of back and buttocks serve to allow drainage from the lungs, stimulates the medulla by rush of blood by gravity and by reflex action through the skin, aids in respiration. It should be then plunged into the hot bath at once.